USRN with Appeals and Grievance Exp

3 days ago

Manila, National Capital Region, Philippines UST Full time

UST is searching for an A&G USRN who will independently take customer support calls effectively and efficiently; follow the SOPs to complete the process and endeavor to resolve the issue, handle some escalated issues or escalate to a more knowledgeable person to resolve, in alignment with SLAs; and assists the Lead.

In this role, you should independently be able to effectively and efficiently process the transactions assigned in a timely manner, clarify complex transactions to others and ensure that quality of output and accuracy of information is maintained, in alignment with SLAs.

Responsibilities:

Investigate and process complex grievances and appeals requests from members and providersPerform reviews of inpatient, outpatient, ambulatory and ancillary services for medical necessityReview, research, and prepare documentation related to appeals and grievances in accordance with local, state, and federal regulatory and designated accreditation (e.g., NCQA) standardsPrepare recommendations to either uphold or deny appeal and work with the Medical Director for further reviewDocument and logs appeal/grievance information on relevant tracking systemsGenerate written correspondence to providers, members, and regulatory entitiesServe as a subject matter expert for appeals, grievances, and quality of care issues Requirements:Current, unrestricted, mainland USRN license2-4 years of clinical experience which may include acute patient care, discharge planning, case management, utilization review, etc.Appeals and grievance experience requiredDemonstrated clinical knowledge and experience relative to patient care and healthcare delivery processesMedicare Advantage experience preferredExcellent written and verbal communication skillsExcellent customer service and interpersonal skillsAbility to apply clinical criteria/guidelines for medical necessity, setting/level of care, and concurrent patient managementKnowledge of current standard medical procedures/practices and their application as well as current trends and developments in medicine and nursing, alternative care settings, and levels of serviceKnowledge of policies and procedures, member benefits, and community resourcesKnowledge of applicable accreditation standards, and local, state, and federal regulationsStrong problem-solving skills, facilitation skills, and analytical skillsFlexible to work in globally distributed teams as needed, and at times support weekend shifts

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